Translate this page into:
Restrictive Versus Liberal Fluid Guideline to Practice in Acute Respiratory Distress Syndrome Secondary to Sepsis – Reality in a Tertiary Care Center
*Corresponding author: Atul Aman, Department of Trauma and Emergency Medicine, All India Institute of Medical Sciences, Kalyani, West Bengal, India. dratulaman@gmail.com
-
Received: ,
Accepted: ,
How to cite this article: Anand R, Singh R, Kumar S, Aman A, Kumar M, Naskar B. Restrictive Versus Liberal Fluid Guideline to Practice in Acute Respiratory Distress Syndrome Secondary to Sepsis – Reality in a Tertiary Care Center. J Card Crit Care TSS. 2025;9:219-25. doi: 10.25259/JCCC_28_2025
Abstract
Objectives:
Sepsis is a leading cause of acute respiratory distress syndrome (ARDS) worldwide. Effective fluid management strategies are essential for treating these patients. This research assesses the practical implementation and outcomes of restrictive versus liberal fluid management approaches in ARDS caused by sepsis. The aim of the study is to assess the clinical outcomes linked to various fluid management strategies in real-world scenarios, providing insights to optimize clinical practices and develop personalized treatment protocols for very sick patients with ARDS.
Material and Methods:
This retrospective observational study included 120 patients with ARDS due to sepsis. They were treated at a tertiary care center in India between June 2022 and January 2024. Patients were categorized into restrictive fluid groups (RGs) and liberal fluid groups (LGs). 28-day mortality was considered the primary outcome, while the secondary outcomes included the period of ventilatory support, intensive care unit (ICU) length of stay, incidence of renal failure, need for renal replacement therapy (RRT), and new organ dysfunction.
Results:
Patients in the RG had a significant decline in 28-day mortality (25% vs. 40%, P = 0.043) and shorter period of ventilatory support (8 days vs. 12 days, P = 0.001) compared to the LG. ICU length of stay was also reduced (12 days vs. 16 days, P = 0.028). The incidence of renal failure or need for RRT was insignificant between groups. However, the incidence of new organ dysfunction was significant between groups.
Conclusion:
Restrictive fluid management in ARDS resulting from sepsis has been linked to better survival rates, shorter periods of mechanical ventilation, and reduced ICU stays. These results advocate for adopting restrictive fluid strategies.
Keywords
Acute respiratory distress syndrome
Fluid management
Intensive care unit
Mechanical ventilation
Mortality
Sepsis
INTRODUCTION
Sepsis is the leading cause of acute respiratory distress syndrome (ARDS) worldwide. Hypoxemia due to an acute onset and bilateral pulmonary infiltrates that cannot be entirely attributed to cardiac failure or fluid overload leads to multiorgan failure.[1] Effective management of ARDS, remarkably fluid management, is essential for enhancing patient outcomes and lowering mortality rates.[2]
Fluid management in ARDS is a critical aspect of supportive care as it directly impacts lung mechanics, gas exchange, and overall patient outcomes.[3] Fluid strategies can be broadly divided into restrictive and liberal approaches. Restrictive fluid management minimizes fluid intake and promotes a negative fluid balance to reduce pulmonary edema and improve oxygenation.[4] In contrast, liberal fluid management involves administering fluids generously to ensure adequate organ perfusion, accepting a positive fluid balance to avoid hypovolemia, and maintaining tissue perfusion.[5]
The debate between restrictive and liberal fluid strategies is driven by the complex pathophysiology of ARDS and the systemic inflammatory response in sepsis. Sepsis triggers a systemic inflammatory response, increasing capillary permeability and fluid accumulation in the interstitial and alveolar compartments. This process aggravates pulmonary edema and compromises oxygen exchange.[6] As a result, excessive fluid administration may deteriorate lung function, extend the need for mechanical ventilation, and lengthen intensive care unit (ICU) stays.[7] Conversely, insufficient fluid resuscitation may result in hypoperfusion, multi-organ dysfunction, and elevated mortality rates.[8]
The Fluids and Catheters Treatment Trial (FACTT) recommended conservative versus liberal fluid management. This study suggested that a conservative fluid strategy to maintain neutral or negative fluid balance resulted in improved lung function.[9] These findings have significantly influenced clinical practice guidelines, advocating for a more restrictive fluid management approach in ARDS.
Managing fluid balance in sepsis-induced ARDS presents challenges. Early and aggressive fluid resuscitation is advised to improve cardiac output and enhance tissue perfusion.[10] However, transitioning to restrictive strategies after stabilization remains controversial due to the risks of hypoperfusion and organ dysfunction.[11]
Several studies have shown the effects of restrictive versus liberal fluid management in ARDS. A systematic review reported that a conservative fluid approach was linked to reduced mortality and associated with fewer ventilatory support days in ARDS patients.[12] Restrictive fluid management led to shorter ICU stays and better survival outcomes in cases of sepsis-induced ARDS.[13] These results emphasize the advantages of restrictive fluid strategies in ARDS while highlighting the importance of tailoring treatment to individual patient needs.
Despite accumulating evidence supporting restrictive fluid management, no consensus exists on its optimal application, particularly in the heterogeneous population of sepsis-induced ARDS. The variability in patient responses, disease severity, and the dynamic nature of sepsis necessitate a tailored approach to fluid management.[1] Moreover, real-world data on the implementation and outcomes of these fluid strategies in diverse healthcare settings are limited.[14] Biomarkers and bedside ultrasound are increasingly explored to enhance precision in fluid management decisions. Personalized approaches, considering individual patient characteristics such as comorbidities, baseline cardiac function, and response to initial resuscitation, are crucial for improving outcomes. Future research should focus on establishing standardized protocols that balance the need for adequate perfusion with the risk of fluid overload, aiming to improve survival and reduce long-term complications in ARDS patients.
This study aims to assess the clinical outcomes linked to various fluid management strategies in real-world scenarios, providing insights to optimize clinical practices and develop personalized treatment protocols for critically ill patients with ARDS and sepsis. The results are expected to deepen our understanding of fluid management in this complex patient group and contribute to refining guidelines to enhance patient care and outcomes.
MATERIAL AND METHODS
Study design
This retrospective observational study was carried out at the tertiary center of India after receiving approval from the Ethical Committee of the institute and being registered with the Indian clinical trial registry (CTRI) Registration no. CTRI/2022/04/042303. It spanned from June 2022 to January 2024 and focused on patients diagnosed with ARDS due to sepsis.
Selection criteria for participants
A total of 120 patients were diagnosed with ARDS following sepsis, adhering to specific inclusion and exclusion criteria. Participants were adults, confirmed to have sepsis and ARDS as per sepsis-3 criteria and the Berlin definition, respectively, and were admitted to the ICU during the study period. The exclusion criteria were age <18 years, pregnant patients, patients with chronic respiratory conditions precluding ARDS diagnosis, and patients with incomplete medical records.
Data collection
It was obtained retrospectively from patient records, encompassing demographic information (age and gender), clinical parameters (comorbidities, acute physiology and chronic health evaluation [APACHE II], and sequential organ failure assessment [SOFA]), and treatment details (fluid management strategy, vasopressor use, and mechanical ventilation settings applied during their ICU admission).
Fluid management approach
Patients were categorized into 2 groups based on the fluid management approach received during their ICU stay.
A restrictive fluid group (RG): Adopts a conservative fluid management strategy to limit fluid accumulation. This approach typically involved maintaining a net fluid balance close to zero or slightly negative, carefully monitoring fluid inputs and outputs, and early use of diuretics.
A liberal fluid group (LG): This group received a liberal fluid management approach focusing on ensuring adequate tissue perfusion. This strategy involved aggressive fluid resuscitation, aiming to optimize hemodynamic and organ perfusion with less stringent monitoring of fluid balance.
Restrictive fluid management minimizes fluid accumulation in the lungs, thereby reducing pulmonary edema and improving oxygenation. This approach is supported by studies suggesting better outcomes regarding oxygenation, duration of ventilatory support, and overall mortality. However, it poses the risk of inadequate tissue perfusion, potentially exacerbating organ dysfunction. However, liberal fluid administration ensures sufficient organ perfusion and addresses potential hypovolemia but increases the fluid overload risk, worsening pulmonary edema and delaying weaning from mechanical ventilation.
The clinical application of these strategies in ARDS secondary to sepsis is further complicated by the heterogeneity of patient responses and underlying pathophysiological conditions. Despite numerous studies, no consensus remains on optimal fluid management, necessitating individualized patient care and continuous assessment. This study aims to evaluate the real-world implementation and outcomes of restrictive versus liberal fluid guidelines in a tertiary care setting, providing insights into their practical effectiveness and impact on patient outcomes. By analyzing data from a tertiary care center, this research seeks to bridge the gap between clinical guidelines and everyday practice, contributing to the ongoing discourse on optimal fluid management in ARDS secondary to sepsis.
Outcomes measured
28-day mortality was measured as the primary outcome, while the secondary outcomes included duration of ventilatory support, ICU length of stay, incidence of renal failure, need for renal replacement therapy (RRT), new organ dysfunction, and fluid balance after 24, 48, and 72 h of admission.
Statistical analysis
It was performed using the Statistical Package for the Social Sciences version 25.0. Continuous variables were reported as means ± standard deviation (SD) or medians interquartile range (IQR) and categorical variables as frequencies and percentages. Group comparisons used the Student’s t-test or Mann–Whitney U-test for continuous data and the Chi-square or Fisher’s exact test for categorical data. Kaplan– Meier survival curves assessed 28-day mortality, with significance tested by the log-rank test. A Cox proportional hazards model identified independent mortality predictors and adjusted for confounders. A P < 0.05 was considered statistically significant.
Results interpretation
The data collected from the 120 patients provided a comprehensive overview of the outcomes associated with different fluid management strategies in ARDS secondary to sepsis. By comparing the restrictive and liberal fluid management approaches, the study aimed to identify which strategy resulted in better clinical outcomes, thereby contributing valuable insights to the ongoing debate on optimal fluid management in ARDS.
RESULTS
Patient demographics and baseline characteristics
The study enrolled 120 participants diagnosed with ARDS secondary to sepsis. The mean age of the participants was 58 ± 15 years, with 70 (58.3%) males and 50 (41.7%) females. Baseline characteristics, including comorbidities and APACHE II and SOFA, were comparable between the two groups, ensuring homogeneity and minimizing bias [Table 1]. No significant differences were observed between restrictive and liberal groups regarding age, gender distribution, or baseline severity scores, suggesting both cohorts were well-matched for comparative analysis.
| Characteristic | RG (n=60) | LG (n=60) | *P-value |
|---|---|---|---|
| Age (years) | 57.2±14.8 | 59.1±15.2 | 0.432 |
| Male, n (%) | 34 (56.7) | 36 (60.0) | 0.713 |
| +APACHE II score | 22.1±5.3 | 21.7±5.8 | 0.667 |
| #SOFA score | 9.5±2.1 | 9.8±2.4 | 0.462 |
| Diabetes, n (%) | 18 (30.0) | 20 (33.3) | 0.701 |
| Hypertension, n (%) | 24 (40.0) | 22 (36.7) | 0.712 |
| Chronic kidney disease, n (%) | 12 (20.0) | 14 (23.3) | 0.669 |
+APACHE II: Acute physiology and chronic health evaluation II, #SOFA Score: Sequential organ failure assessment, *P-Value for comparison between the two groups (P<0.05), ±Confidence interval, RG: Restrictive group, LG: Liberal group
Primary and secondary outcomes
Mortality
28-day mortality was significantly lower in RG, 15 (25%), compared to LG, 24 (40%), with a P = 0.043. The Kaplan– Meier survival curves [Figure 1] further illustrate a statistically significant survival advantage for patients in the restrictive group, emphasizing the potential impact of fluid management strategies on patient survival.
- Kaplan–Meier survival curves for 28-day mortality. RG: Restrictive fluid group LG: Liberal fluid group.
Patients in the restrictive group experienced a shorter median duration of mechanical ventilation (8 days [IQR 5–12]) compared to the liberal group, which had a median duration of 12 days (IQR 8–16), with a P = 0.001. This finding underscores the effectiveness of restrictive fluid management in reducing the dependency on mechanical ventilation, which may help decrease associated complications.
ICU length of stay
The median stay was notably shorter in the restrictive group (10 days [IQR 7–14]) than in the liberal group (15 days [IQR 10–18]), P < 0.001. This reduction in ICU stay may translate to lower healthcare costs and reduced risk of ICU-acquired infections.
RRT
The incidence of RRT was lower in the restrictive fluid management group, with 6 out of 60 patients (10%) needing intervention, compared to 12 out of 60 patients (20%) in the liberal fluid management group. However, this difference did not reach statistical significance (P = 0.145). Despite the lack of statistical significance, the trend indicates a potential benefit of restrictive fluid management in protecting renal function.
New organ dysfunction
The incidence of new organ dysfunction was significantly lower in the restrictive group 9 (15%) compared to the liberal group 18 (30%), P = 0.047. This finding indicates that restrictive fluid management may help preserve organ function and reduce systemic complications associated with fluid overload [Table 2].
| Outcome | Restrictive Group (n=60) | Liberal Group (n=60) | *P-value |
|---|---|---|---|
| 28-day mortality, n (%) | 15 (25.0) | 24 (40.0) | 0.043 |
| Duration of mechanical ventilation (days) | 8 (5−12) | 12 (8−16) | 0.001 |
| Length of ICU stay (days) | 10 (7−14) | 15 [10−18] | <0.001 |
| Renal replacement therapy, n (%) | 6 (10.0) | 12 (20.0) | 0.145 |
| New organ dysfunction, n (%) | 9 (15.0) | 18 (30.0) | 0.047 |
Fluid balance
Fluid balance assessments at 24, 48, and 72 h post-admission demonstrated consistently more negative balances in the restrictive group compared to the liberal group [Table 3]. At 24 h, the median fluid balance in the restrictive group was −500 mL (IQR −800 to −200) versus + 600 mL (IQR 300–900) in the liberal group (P < 0.001). Similar trends were observed at 48 and 72 h, with the restrictive group maintaining negative balances of −700 mL and −900 mL, respectively, compared to positive balances of +800 mL and +1000 mL in the liberal group (P < 0.001). These findings emphasize the efficacy of restrictive strategies in achieving negative fluid balance, which may contribute to improved pulmonary function and reduced edema.
| Time point | Restrictive group (n=60) | Liberal group (n=60) | *P-value |
|---|---|---|---|
| 24 h (mL) | −500 [−800–−200] | +600 [300–900] | <0.001 |
| 48 h (mL) | −700 [−1000–−400] | +800 [500–1100] | <0.001 |
| 72 h (mL) | −900 [−1200–−600] | +1000 [700–1300] | <0.001 |
Clinical significance
The results of this study highlight the potential benefits of a restrictive fluid management strategy in ARDS patients. The statistically significant improvements in 28-day mortality, mechanical ventilation duration, ICU stay, and organ dysfunction underscore the clinical relevance of fluid optimization. Although the differences in RRT rates were not statistically significant, the trend favors restrictive fluid management as a safer approach with fewer complications.
The findings support the hypothesis that restrictive fluid strategies can enhance survival outcomes and reduce ICU resource utilization in ARDS patients secondary to sepsis. These results align with studies emphasizing conservative fluid management and offer robust evidence for incorporating restrictive strategies into clinical practice guidelines.
Future research should aim to validate these findings in larger, multi-center trials and explore the long-term outcomes of fluid management strategies. In addition, investigating biomarkers for fluid responsiveness may further refine individualized treatment approaches in critically ill patients.
DISCUSSION
Fluid management in ARDS secondary to sepsis remains a critical and widely debated topic in intensive care medicine. This retrospective study evaluated the impact of restrictive versus liberal fluid management strategies in a tertiary care setting, providing important insights into their influence on patient outcomes.
Our study’s findings are consistent with previous research, suggesting that restrictive fluid management enhances outcomes in ARDS patients. The FACTT trial showed that a conservative fluid strategy is better for ARDS management. The advantages of a conservative study include a shorter mechanical ventilation period and improved oxygenation without increasing the risk of shock or dialysis.[1] Our study also finds similar results.
The complex interplay between adequate organ perfusion and the prevention of pulmonary edema highlights the importance of fluid management in sepsis-induced ARDS. Sepsis increases vascular permeability, resulting in pulmonary edema and hypoxemia.[2] The liberal fluid strategy, although aimed at optimizing organ perfusion, can contribute to fluid overload and its associated complications. Our findings of higher 28-day mortality and a higher percentage of new organ dysfunction in the LG corroborate these concerns.
A positive fluid balance was linked with worse outcomes in studies by Rosenberg et al., and Murphy et al.[3,4] The SAFE study and subsequent analyses have underscored the detrimental effects of fluid overload, particularly in ARDS patients.[5] Our study supports this view, as the RG had a more negative fluid balance at 24, 48, and 72 h, which was associated with better clinical outcomes. This suggests that meticulous fluid management to avoid fluid overload is crucial in managing ARDS secondary to sepsis.
Our study also aligns with the findings of the FACTT Lite trial, which emphasized the need for a balanced approach to fluid management, tailoring fluid therapy to the individual patient’s needs.[6] Considering the dynamic changes in hemodynamic and fluid responsiveness, personalized fluid management strategies are increasingly essential in critical care.[7] The restrictive fluid strategy in our study likely benefited from such a tailored approach, minimizing fluid accumulation while ensuring adequate perfusion.
The mortality benefit observed in the RG of our study aligns with the results of several meta-analyses. Restrictive fluid strategy found positive outcomes in patients with acute kidney injury.[8] Similarly, a fluid management meta-analysis in sepsis patients found that patients who received a restrictive fluid strategy required less ventilatory support and hospital stay. These meta-analyses further support the potential survival advantage of restrictive fluid management in ARDS.[9]
The potential benefits of a restrictive fluid strategy include reduced risk of hypoperfusion and organ dysfunction. In our study, the incidence of RRT was lower in the restrictive group, which was not statistically significant. This suggests that the risk of hypoperfusion can be minimized with careful monitoring, ensuring that restrictive fluid management does not impair renal function.[10,11]
The impact of fluid management on other organ systems, such as the heart and liver, is also an important consideration. Positive fluid balance has been associated with increased cardiac filling pressures and impaired liver function, further complicating the management of critically ill patients.[12,13] Our study did not specifically assess the impact of fluid management on these organ systems. Still, the lower incidence of new organ dysfunction in the restrictive group suggests a broader benefit of this strategy.
Wiedemann et al.[1] contributed significantly to this discourse by comparing two fluid-management strategies in patients with acute lung injury. This reinforces that judicious fluid management can enhance outcomes in critically ill populations.[1]
Building on this, Wang et al. found that a higher cumulative fluid balance was associated with increased mortality, thereby underscoring the detrimental effects of fluid overload, particularly in vulnerable patient cohorts. This aligns with the growing literature advocating more conservative fluid management practices.[14]
In a broader context, Herridge et al. discussed strategies for improving lung care in the ICU, advocating for interventions that limit fluid overload and optimize ventilation strategies.
Their insights underline the importance of interdisciplinary critical care approaches prioritizing fluid management and respiratory support.[15]
A landmark study by the National Heart, Lung, and Blood Institute ARDS clinical trial further solidified the critical nature of ventilation strategies in managing acute lung injury and ARDS. Their recommendation for lower tidal volume ventilation complements the discussion of fluid management by illustrating how respiratory support and fluid management can collectively influence patient outcomes.[16]
Messina et al.[17] provided a practical framework for the careful use of fluid challenges in intensive care, offering ten guiding principles to optimize fluid resuscitation while mitigating risks associated with fluid overload. Their recommendations are valuable for clinicians striving to balance adequate hydration with the potential for adverse effects in critically ill patients.[17]
Finally, Sakr et al.[18] observed that a positive fluid balance significantly enhances the risk of mortality from sepsis, reinforcing the importance of monitoring fluid status in this high-risk population. Their findings contribute to the evidence that excessive fluid administration can lead to poor outcomes, particularly in septic patients.[18]
In line with these findings, the surviving sepsis campaign guidelines (Dellinger et al.)[19] stress the necessity of early and appropriate fluid resuscitation in the management of severe sepsis and septic shock. However, these guidelines also emphasize reassessing fluid status regularly to prevent fluid overload and its associated complications.[19]
The retrospective study design may pose risks of bias due to potential inaccuracies or incomplete medical records, which is a limitation of our study. Furthermore, the study’s findings, conducted at a single center, may not be fully generalizable to other settings. Nonetheless, the study provides important insights into fluid management practices in a tertiary care center in India, laying the groundwork for future prospective studies. By meticulously analyzing the outcomes associated with restrictive versus liberal fluid management in ARDS secondary to sepsis, this study seeks to provide insights to inform clinical practice and support the development of evidence-based guidelines.[20-22]
CONCLUSION
The restrictive fluid management approach in patients with ARDS caused by sepsis is associated with lower 28-day mortality. It also highlighted shorter durations of mechanical ventilation, reduced ICU stays, and fewer occurrences of new organ dysfunction. These results emphasize the potential benefits of adopting a conservative fluid strategy. Further research should focus on optimizing fluid management protocols, integrating dynamic tools to assess fluid responsiveness, and confirming these findings through larger, prospective studies. Improving fluid management practices may enhance outcomes for patients facing this serious and fatal situation.
Ethical approval:
The research/study approved by the Institutional Review Board at Indira Gandhi Institute of Medical Sciences, Patna, number 511/IEC/IGIMS/2022, dated 1st April, 2022.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
References
- Comparison of Two Fluid-Management Strategies in Acute Lung Injury. N Engl J Med. 2006;354:2564-75.
- [CrossRef] [PubMed] [Google Scholar]
- Albumin and Furosemide Therapy in Hypoproteinemic Patients with Acute Lung Injury. Crit Care Med. 2002;30:2175-82.
- [CrossRef] [PubMed] [Google Scholar]
- Review of a Large Clinical Series: Association of Cumulative Fluid Balance on Outcome in Acute Lung Injury: A Retrospective Review of the ARDSnet Tidal Volume Study Cohort. J Intensive Care Med. 2009;24:35-46.
- [CrossRef] [PubMed] [Google Scholar]
- The Importance of Fluid Management in Acute Lung Injury Secondary to Septic Shock. Chest. 2009;136:102-9.
- [CrossRef] [PubMed] [Google Scholar]
- A Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit. N Engl J Med. 2004;350:2247-56.
- [CrossRef] [PubMed] [Google Scholar]
- Fluid Management in Sepsis. J Intensive Care Med. 2019;34:364-73.
- [CrossRef] [PubMed] [Google Scholar]
- Predicting Fluid Responsiveness in ICU Patients: A Critical Analysis of the Evidence. Chest. 2002;121:2000-8.
- [CrossRef] [PubMed] [Google Scholar]
- Deresuscitation of Patients with Iatrogenic Fluid Overload is Associated with Reduced Mortality in Critical Illness. Crit Care Med. 2018;46:1600-7.
- [CrossRef] [PubMed] [Google Scholar]
- Fluid Resuscitation in Sepsis: A Systematic Review and Network Meta-Analysis. Ann Intern Med. 2014;161:347-55.
- [CrossRef] [PubMed] [Google Scholar]
- Using Pulse Pressure Variation or stroke Volume Variation to Diagnose Right Ventricular Failure? Crit Care. 2010;14:451.
- [CrossRef] [PubMed] [Google Scholar]
- Dynamic Changes in Arterial Waveform Derived Variables and Fluid Responsiveness in Mechanically Ventilated Patients: A Systematic Review of the Literature. Crit Care Med. 2009;37:2642-7.
- [CrossRef] [PubMed] [Google Scholar]
- Fluid Resuscitation in Septic Shock: A Positive Fluid Balance and Elevated Central Venous Pressure are Associated with Increased Mortality. Crit Care Med. 2011;39:259-65.
- [CrossRef] [PubMed] [Google Scholar]
- Association between Fluid Balance and Survival in Critically Ill Patients. J Intern Med. 2015;277:468-77.
- [CrossRef] [PubMed] [Google Scholar]
- Fluid Balance and Mortality in Critically Ill Patients with Acute Kidney Injury: A Multicenter Prospective Epidemiological Study. Crit Care. 2015;19:371.
- [CrossRef] [PubMed] [Google Scholar]
- One-Year Outcomes in Survivors of the Acute Respiratory Distress Syndrome. N Engl J Med. 2003;348:683-93.
- [CrossRef] [PubMed] [Google Scholar]
- Ventilation With Lower Tidal Volumes As Compared With Traditional Tidal Volumes For Acute Lung Injury And The Acute Respiratory Distress Syndrome. N Engl J Med. 2000;342:1301-8.
- [CrossRef] [PubMed] [Google Scholar]
- Fluid Challenge in Critically Ill Patients Receiving Haemodynamic Monitoring: A Systematic Review and Comparison of Two Decades. Crit Care. 2022;26:186.
- [CrossRef] [PubMed] [Google Scholar]
- Higher Fluid Balance Increases the Risk of Death From Sepsis: Results from a Large International Audit. Crit Care Med. 2017;45:386-94.
- [CrossRef] [PubMed] [Google Scholar]
- Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. Crit Care Med. 2013;41:580-637.
- [CrossRef] [PubMed] [Google Scholar]
- Thromboelastography in Venovenous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. J Card Crit Care. 2017;1:101-4.
- [CrossRef] [Google Scholar]
- Does Intraoperative Diuretic Therapy Affect the Thoracic Fluid Content and Clinical Outcome in Patients Undergoing Mitral Valve Surgery? J Card Crit Care. 2020;4:86-90.
- [CrossRef] [Google Scholar]
- Sepsis Associated with Extracorporeal Membrane Oxygenation. J Card Crit Care. 2022;6:146-50.
- [CrossRef] [Google Scholar]